Acknowledgment of MTA Call-a-Ride Premium Service Policy

Acknowledgment of MTA Call-a-Ride Premium Service Policy
MTA Mobility ID Number 274868

PERSONAL INFORMATION

Customer Printed Name

Address

APT#	City		State

Zip	Home Phone		Cell Phone

Date of Birth	Email Address

Emergency Contact Name and Phone

In order to participate in the following MTA Mobility premium services, this acknowledgement form must be signed and returned to
Mobility Premium Services 4201 Patterson Ave 1st floor Baltimore MD 21215

SERVICE ENROLLMENT INFOMATION
Please indicate which services you are enrolling in:

MTA Call-a-Ride, Policy dated October 4, 2021

MTA Call-a-Ride Center, Policy dated October 4, 2021 (Dialysis Patients Only)

Dialysis Center Address

By signing below you are stating that you understand and agree to abide to the policies of each service indicated.

MTA Customer signature (must sign)		Date

If you are unable to read the policy(s) and sign this form without assistance, please have the person assisting you sign the form sign below certifying that they read the policy(s) to you and that you have indicated your agreement to abide by the policies.

Signature of Person Assisting		Date

Printed Name

SERVICE AREA INFORMATION

Do you reside in the Service Area? (See MTA Call-A-Ride Policies)

By signing below, I confirm that I have been informed that my residence is located outside of the MTA Mobility and MTA Call-a-Ride Services area.

Customer signature		Date

Please provide a pick-up address that is inside of MTA Mobility's Service Area below

Alternative Pick-Up Address:

City:	State:		Zip:

Please review the following: